Get Fl 900-502-0511 2011-2026

The FL 900-502-0511 form is essential for updating provider information with Blue Cross and Blue Shield of Florida. This guide will provide clear, step-by-step instructions to ensure a smooth online completion process.

Follow the steps to complete your FL 900-502-0511 form online.

1. Click ‘Get Form’ button to access the online form and open it for editing.
2. Complete Section I by entering your full name, title, provider number, individual and organizational NPI, Medicare number, medical license number, tax ID or social security number, specialty, effective date of request, office contact name, telephone number, and email address. Make sure to provide legal documentation for any changes to your last name.
3. In Section II, list the languages spoken by the provider or staff in order of fluency. If a language is spoken by staff only, indicate this by checking the 'Staff' box.
4. For Section III, indicate any changes to your service location. You may need to fill out a separate form for each new location. Specify whether the location is new, relocated, expired, or a correction to an existing location, and provide the relevant address details.
5. Enter your office hours in Section IV for each day of the week, specifying both morning and afternoon shifts.
6. Section V requires updates to your payment or billing address. Provide previous and new addresses, along with the respective contact details. Remember, a signature from the tax ID owner is needed for changes.
7. To update your tax identification number in Section VI, enter the previous and new TIN/EIN and effective date of change. Remember to attach a completed W-9 form.
8. In Section VII, provide any updates regarding hospital affiliations. This includes entering the hospital name, provider number, hospital NPI, and indicating whether to add or delete the affiliation.
9. Section VIII is for any deletions of professional associations, including the group NPI and effective date of disassociation. Include your printed name, signature, title, and date.
10. After filling out the necessary sections, review your information for accuracy. You can then save changes, download, print, or share the completed form as required.

Begin the process of completing your FL 900-502-0511 form online today!